Experience with Robotic Lobectomy for Lung Cancer

Lung Cancer Treatment: From Tradition to Innovation

Lung cancer (LC) is the second most commonly diagnosed cancer and the primary cause of cancer death worldwide in 2020. LC treatment is associated with huge costs for patients and society; consequently, there is an increasing interest in the prevention, early detection with screening, and development of new treatments. Its surgical management accounts for at least 90% of the activity of thoracic surgery departments. Surgery is the treatment of choice for early-stage non-small cell LC. In this article, we discuss the state of the art of thoracic surgery for surgical management of LC. We start by describing the milestones of LC treatment, which are lobectomy and an adequate lymphadenectomy, and then we focus on the traditional and innovative minimally invasive surgical approaches available: video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS). A brief overview of the innovation and future perspective in thoracic surgery will close this mini-review.

Training residents in robotic thoracic surgery

With growing integration of robotic technology in thoracic surgery, the need for structured training has never been greater with trainees expressing desire for additional experience. Determining the ideal education program is challenging as the collective experience is still relatively early and growing with many experienced surgeons still becoming facile with the platform. Understanding differences between robotic and thoracoscopic approaches including lung retraction and dissection, use of carbon dioxide insufflation, and lack of tactile feedback serves as the foundation for building a skillset. Currently, there is no standard accepted curriculum for residents. Inclusion of these trainees in structured programs has been shown to be safe with equivalent patient outcomes. There are multiple curricula under development, all of which incorporate use of simulation technology, dual console, and clear, graduated responsibilities within operations. These include introduction to the robotic system prior to progressing to bedside assistance and finally to time as console surgeon. The importance of clear definition of training milestones with deliberate graduation to more complex tasks once competency has been demonstrated cannot be overstated. It is crucial for surgeons practicing robotic surgery to make efforts to further the training of residents, but there has not been any perfect and suitable program identified yet.

Perioperative Outcome of Robotic Approach Versus Manual Videothoracoscopic Major Resection in Patients Affected by Early Lung Cancer: Results of a Randomized Multicentric Study (ROMAN Study)

Introduction

We report the results of the first prospective international randomized control trial to compare the perioperative outcome and surgical radicality of the robotic approach with those of traditional video-assisted surgery in the treatment of early-stage lung cancer.

Methods

Patients with clinical stage T1–T2, N0–N1 non-small cell lung cancer (NSCLC) were randomly assigned to robotic-assisted thoracoscopic surgery (RATS) or video-assisted thoracic surgery (VATS) resection arms. The primary objective was the incidence of adverse events including complications and conversion to thoracotomy. The secondary objectives included extent of lymph node (LN) dissection and other indicators.

Results

This trial was closed at 83 cases as the probability of concluding in favor of the robot arm for the primary outcome was null according to the observed trend. In this study, we report the results of the analysis conducted on the patients enrolled until trial suspension. Thirty-nine cases were randomized in the VATS arm and 38 in the robotic arm. Six patients were excluded from analysis. Despite finding no difference between the two arms in perioperative complications, conversions, duration of surgery, or duration of postoperative stay, a significantly greater degree of LN assessment by the robotic technique was observed in regards to the median number of sampled LN stations [6, interquartile range (IQR) 4–6 vs. 4, IQR 3–5; p = 0.0002], hilar LNs (7, IQR 5–10 vs. 4, IQR 2–7; p = 0.0003), and mediastinal LNs (7, IQR 5–10 vs. 5, IQR 3–7; p = 0.0001).

Conclusions

The results of this trial demonstrated that RATS was not superior to VATS considering the perioperative outcome for early-stage NSCLC, but the robotic approach allowed an improvement of LN dissection. Further studies are suggested to validate the results of this trial.

Clinical Trial Registration

clinicaltrials.gov, identifier NCT02804893.

Analysis of the short-term outcomes of biportal robot-assisted lobectomy

BACKGROUND

The present study aimed to assess the short-term consequences of biportal robot-assisted lobectomy, validating its safety and effectiveness.

METHODS

A retrospective analysis evaluated the clinical data and short-term results of 18 patients in the single medical group of the centre who underwent biportal robot-assisted lobectomy plus lymph node dissection from November 2020 to March 2021.

RESULTS

Lobectomy and lymph node dissection could be successfully accomplished in all 18 patients with the assistance of a biportal robot; there was no conversion to thoracotomy during the operation. There were 10 males and 8 females with their ages ranging from 37 to 73 (58.83 ± 9.07) years. The total operation time was 74-146 (105.06 ± 18.22) min. Punching time was 2-9 (5.11 ± 1.74) min. Docking time was 8-16 (11.94 ± 2.41) min. Console time was 50-104 (78.06 ± 17.40) min. Chest closing time was 8-17 (10.28 ± 2.74) min. Blood loss was 60-132 (94.11 ± 41.41) ml. The number of lymph nodes dissected was 16-30 (21.78 ± 4.13). Chest tube duration was 2-10 (4.06 ± 1.98) days. Drainage on the first day following surgery was 100-500 (337.22 ± 117.01) ml. Total drainage was 370-1100 (692.78 ± 161.01) ml. Duration of hospital stay was 4-12 (5.89 ± 1.94) days. The median 24 and 72 h visual analogue score scores were 4 (3-7) and 3 (2-5). Total cost (¥) was 51 000-85 000 (68 000 ± 10 000), respectively. There was one case of atrial fibrillation and one case of pulmonary infection. The complication rate was 11.11%. No serious complications were recorded after surgery, and no deaths occurred within 30 days post-surgery. The final pathological diagnosis revealed 10 cases of squamous cell carcinoma, 7 cases of adenocarcinoma and 1 case of benign disease.

CONCLUSION

The biportal robot-assisted lobectomy was found to be safe and effective in the treatment of lung cancer.

Simulation training for lobectomy: a review of current literature and future directions†

With growing work-time restrictions and public expectations, the Halstedian educational model of 'see one, do one, teach one' is unfit for the modern training of thoracic residents. With the cardiothoracic surgical workforce set to decline by 50% over the next 10 years, new models are desperately needed to help trainees bypass the early error-prone phase of the lobectomy learning curve. In this review, we detail the development and validation of numerous simulators designed to teach trainees an array of skills ranging from basic technical skills to more complex non-technical skills. Given the recent increases in minimally invasive lobectomies, we critique both open and thoracoscopic simulators. We elucidate that whilst there are a growing number of thoracic simulators of varying fidelity available, fundamentally, there is currently a significant lack of well-designed trials validating various simulators for teaching lobectomy despite an awareness of their potential to improve surgical education. Furthermore, there is a void in the simulation training of non-technical skills within thoracic surgery. Encouragingly, there is a definite awareness of the ability of simulation to aid with the training of future thoracic surgical trainees.

Switching from Thoracoscopic to Robotic Platform for Lobectomy: Report of Learning Curve and Outcome

OBJECTIVE

The optimal minimally invasive surgical management for patients with non-small-cell lung cancer (NSCLC) is unclear. For experienced video-assisted thoracoscopic surgery (VATS) surgeons, the increased costs and learning curve are strong barriers for adoption of robotics. We examined the learning curve and outcome of an experienced VATS lobectomy surgeon switching to a robotic platform.

METHODS

We conducted a retrospective review to identify patients who underwent a robotic or VATS lobectomy for NSCLC from 2016 to 2018. Analysis of patient demographics, perioperative data, pathological upstaging rates, and robotic approach (RA) learning curve was performed.

RESULTS

This study evaluated 167 lobectomies in total, 118 by RA and 49 by VATS. Patient and tumor characteristics were similar. RA had significantly more lymph node harvested (14 versus 10; P = 0.004), more nodal stations sampled (5 versus 4; P < 0.001), and more N1 nodes (8 versus 6; P = 0.010) and N2 nodes (6 versus 4; P = 0.017) resected. With RA, 22 patients were upstaged (18.6%) compared to 5 patients (10.2%) with VATS (P = 0.26). No differences were found in perioperative outcome. Operative time decreased significantly with a learning curve of 20 cases, along with a steady increase in lymph node yield.

CONCLUSIONS

RA can be adopted safely by experienced VATS surgeons. Learning curve is 20 cases, with RA resulting in superior lymph node clearance compared to VATS. The potential improvement in upstaging and oncologic resection for NSCLC may justify the associated investments of robotics even for experienced VATS surgeons.

Readmissions After Lobectomy in an Era of Increasing Minimally Invasive Surgery: A Statewide Analysis

Objective

Utilization of minimally invasive surgical modalities for lobectomy is increasing. Lobectomy can be associated with notable rates of readmission. As use of these modalities increases, evaluation of the impact on readmission is warranted.

Methods

Data from the Pennsylvania Health Care Cost Containment Council were used to identify lobectomy operations performed in Pennsylvania from 2011 through 2014. Operations were stratified by approach: open, video-assisted thoracoscopic surgery (VATS) or robotic. Differences in patient characteristics were assessed with analysis of variance and chi-squared tests. Logistic regression modeled risk of 30-day readmission and linear regression modeled length of stay (LOS) after controlling for confounders.

Results

We evaluated 4,939 lobectomy operations (2,501 open, 1,944 VATS, 494 robotic) with 583 readmissions (11.8%). Robotic cases increased 333% over 4 years. VATS and open cases increased 38% and 22%, respectively. Surgical approach was not associated with hospital readmission (VATS odds ratio (OR) = 0.95; P = 0.632; and robotic OR = 1.02; P = 0.916). Longer LOS was associated with a greater likelihood of readmission (OR = 1.58; P = 0.002). LOS was 1 day less for VATS ( P < 0.001) and 1.5 days less for robotic lobectomy ( P < 0.001) when compared to an open approach. The most common reasons for readmission were respiratory complications and nonrespiratory infection.

Conclusions

Surgical approach does not directly affect readmission. However, minimally invasive lobectomy appears to be associated with shorter LOS and results in more patients discharged home. Decreased LOS and discharge home are associated with fewer readmissions.

Outcomes of major complications after robotic anatomic pulmonary resection

BACKGROUND

There is a paucity of robust clinical data on major postoperative complications following robotic-assisted resection for primary lung cancer. This study assessed the incidence and outcomes of patients who experienced major complications after robotic anatomic pulmonary resection.

METHODS

This was a multicenter, retrospective review of patients who underwent robotic anatomic pulmonary resection between 2002 and 2018. Major complications were defined as grade III or higher complications according to the Clavien-Dindo classification. Statistical analysis was performed based on patient-, surgeon-, and treatment-related factors.

RESULTS

During the study period, 1264 patients underwent robotic anatomic pulmonary resections, and 64 major complications occurred in 54 patients (4.3%). Univariate analysis identified male sex, forced expiratory volume in 1 second, diffusion capacity of the lung for carbon monoxide, neoadjuvant therapy, and extent of resection as associated with increased likelihood of a major postoperative complication. Patient age, performance status, body mass index, reoperation status, and surgeon experience did not have a significant impact on major complications. Patients who experienced at least 1 major complication were at higher risk for an intensive care unit stay of >24 hours (17.0% vs 1.4%; P < .001) and prolonged hospitalization (8.5 days vs 4 days; P < .001). Patients who experienced a major postoperative complication had a 14.8% risk of postoperative death.

CONCLUSIONS

In this series, the major complication rate during the postoperative period was 4.3%. A number of identified patient- and treatment-related factors were associated with an increased risk of major complications. Major complications had a significant impact on mortality and duration of stay.

Defining the learning curve of robotic thoracic surgery: what does it take?

BACKGROUND

Controversy exists as to what constitutes a learning curve to achieve competency, and how the initial learning period of robotic thoracic surgery should be approached.

METHODS

We conducted a systematic review of the literature published prior to December 2018 using PubMed/MEDLINE for studies of surgeons adopting the robotic approach for anatomic lung resection or thymectomy. Changes in operating room time and outcomes based on number of cases performed, type of procedure, and existing proficiency with video-assisted thoracoscopic surgery (VATS) were examined.

RESULTS

Twelve observational studies were analyzed, including nine studies on robotic lung resection and three studies on thymectomy. All studies showed a reduction in operative time with an increasing number of cases performed. A steep learning curve was described for thymectomy, with a decrease in operating room time in the first 15 cases and a plateau after 15-20 cases. For anatomic lung resection, the number of cases to achieve a plateau in operative time ranged between 15-20 cases and 40-60 cases. All but two studies had at least some VATS experience. Six studies reported on experience of over one hundred cases and showed continued gradual improvements in operating room time.

CONCLUSION

The learning curve for robotic thoracic surgery appears to be rapid with most studies indicating the steepest improvement in operating time occurring in the initial 15-20 cases for thymectomy and 20-40 cases for anatomic lung resection. Existing data can guide a standardized robotic curriculum for rapid adaptation, and aid credentialing and quality monitoring for robotic thoracic surgery programs.

Incidence, Management, and Outcomes of Intraoperative Catastrophes During Robotic Pulmonary Resection

BACKGROUND

Intraoperative catastrophes during robotic anatomical pulmonary resections are potentially devastating events. The present study aimed to assess the incidence, management, and outcomes of these intraoperative catastrophes for patients with primary lung cancers.

METHODS

This was a retrospective, multiinstitutional study that evaluated patients who underwent robotic anatomical pulmonary resections. Intraoperative catastrophes were defined as events necessitating emergency thoracotomy or requiring an additional unplanned major surgical procedure. Standardized data forms were collected from each institution, with questions on intraoperative management strategies of catastrophic events.

RESULTS

Overall, 1810 patients underwent robotic anatomical pulmonary resections, including 1566 (86.5%) lobectomies. Thirty-five patients (1.9%) experienced an intraoperative catastrophe. These patients were found to have significantly higher clinical TNM stage (P = .031) and lower forced expiratory volume in 1 second (81% vs 90%; P = .004). A higher proportion of patients who had a catastrophic event underwent preoperative radiotherapy (8.6% vs 2.3%; P = .048), and the surgical procedures performed differed significantly compared with noncatastrophic patients. Patients in the catastrophic group had higher perioperative mortality (5.7% vs 0.5%; P = .018), longer operative duration (195 minutes vs 170 minutes; P = .020), and higher estimated blood loss (225 mL vs 50 mL; P < .001). The most common catastrophic event was intraoperative hemorrhage from the pulmonary artery, followed by injury to the airway, pulmonary vein, and liver. Detailed management strategies were discussed.

CONCLUSIONS

The incidence of catastrophic events during robotic anatomical pulmonary resections was low, and the most common complication was pulmonary arterial injury. Awareness of potential intraoperative catastrophes and their management strategies are critical to improving clinical outcomes.

Learning curve for robot-assisted lobectomy of lung cancer

Background

Robotic lobectomy is widely used for lung cancer treatment. So far, few studies have been performed to systematically analyze the learning curve. Our purpose is to define the learning curve to provide a training guideline of this technique.

Methods

A total of 208 consecutive patients with primary lung cancer who underwent robotic-assisted lobectomy by our surgical team were enrolled in this study. Baseline information and postoperative outcomes were collected. Learning curves were then analyzed using the cumulative sum (CUSUM) method. Patients were divided into three groups according to the cut-off points of the learning curve. Intraoperative characteristics and short-term outcomes were compared among the three groups.

Results

CUSUM plots revealed that the docking time, console time and total surgical time in patients were 20, 34 and 32 cases, respectively. Comparison of the surgical time among the 3 phases revealed that the total surgical time (197.03±27.67, 152.61±21.07, 141.35±29.11 min, P<0.001), console time (150.97±26.13, 103.89±18.04, 97.49±24.80 min, P<0.001) and docking time (13.53±2.08, 11.95±1.10, 11.89±1.49 min, P<0.001) were decreased significantly. Estimated blood loss differed among groups (90.63±45.41, 87.63±59.84, 60.29±28.59 mL, P=0.001) and was associated with shorter operative time. There was no conversion or 30-day mortality. No significant differences were observed among other clinic-pathological characteristics among the groups.

Conclusions

For a surgeon, the learning time of robotic lobectomy was in the 32th operation. For a bedside assistant, at least 20 cases were required to achieve the level of optimal docking.

Minimally Invasive Lobectomy Modality and Other Predictors of Conversion to Thoracotomy

OBJECTIVE

Minimally invasive approaches to lobectomy are increasing. Rates of conversion to thoracotomy are well reported but risk factors are poorly understood. This study aimed to determine the impact of surgical modality (video-assisted thoracoscopic surgery [VATS] and robotic) on conversion as well as to identify other risk factors for conversion.

METHODS

The National Cancer Database (NCDB) was used to identify patients who underwent minimally invasive lobectomy between 2010 and 2015. Patient characteristics were compared between VATS and robotic approaches using chi-squared tests and t-tests. Logistic regression models were used to control for covariates and identify factors associated with all minimally invasive conversion, VATS conversion, and robotic conversion. Propensity score matching was used to compare conversion rates of VATS and robotic lobectomy.

RESULTS

The study included 51,723 patients with lung cancer who underwent minimally invasive lobectomy (VATS or robotic). Conversion was identified in 7,109 (7.3%) operations. The odds of VATS conversions were nearly twice that of robotic conversions (OR 1.94 P < 0.0001). After controlling for VATS and robotic patient imbalances with propensity score matching, there was a 5% difference in conversion rates (14% vs. 9%, P < 0.0001). Other predictors of minimally invasive conversion included community hospitals, tumor size 4.5 cm or greater, and an increasing Charlson comorbidity index (P < 0.03 for all).

CONCLUSIONS

VATS is associated with nearly twice the odds of conversion as robotic lobectomy. Identifying specific risk factors for both VATS and robotic conversions may aid in appropriate modality selection and reduction of conversions.

Current status of robot-assisted thoracoscopic surgery for lung cancer

The robotic surgical system was designed to overcome the drawbacks of conventional endoscopic surgery. Since national health insurance in Japan began covering robotic-assisted thoracoscopic surgery (RATS) for malignant lung and mediastinal tumors in 2018, the number of RATS procedures being performed domestically has increased rapidly. This review evaluates the advantages and disadvantages of RATS for patients with lung cancers, based on an electronic literature search of PubMed. The main advantages of RATS are its ability to achieve excellent lymph-node removal with low morbidity and mortality, and minimal postoperative pain. Conversely, its disadvantages include a long operation time and the need for specialized instruments. However, the learning curve for RATS is reported to be shorter than that for VATS: some studies recommend that a surgeon needs to perform 18-22 robotic operations to attain sufficient skill. RATS for lung cancer is more expensive than VATS and the cost of training is high. Although the main disadvantage of RATS is that it reduces operator's tactile senses, the endoscope, which is directly manipulated by the surgeon at the console, using various magnifications, and 3D HD images on the monitor, may compensate for this. Ultimately, RATS offers better maneuverability, accuracy, and stability over VATS.

Learning Curve of Robotic Lobectomy for Early-Stage Non-Small Cell Lung Cancer by a Thoracic Surgeon Adept in Open Lobectomy

OBJECTIVE

The aim of the study was to characterize the clinical outcomes and learning curve during the adoption of a robotic platform for lobectomy for early-stage non-small cell lung cancer by a thoracic surgeon experienced in open thoracotomy.

METHODS

Retrospective review of 157 consecutive patients (57 open thoracotomies, 100 robotic lobectomies) treated with lobectomy for clinical stage I or II non-small cell lung cancer between 2007 and 2014. Clinical outcomes were compared between the open thoracotomy group and five consecutive groups of 20 robotic lobectomies. We used the following six metrics to evaluate learning curve: operative time, conversion to open, estimated blood loss, hospitalization duration, overall morbidity, and pathologic nodal upstaging.

RESULTS

The robotic and open thoracotomy groups had equivalent preoperative characteristics, except for a higher proportion of clinical stage IA patients in the robotic cohort. The robotic group, as a whole, had lower intraoperative blood loss, less overall morbidity, shorter chest tube duration, and shorter length of hospital stay as compared with the open thoracotomy group. Operative time demonstrated a bimodal learning curve. Conversion rate diminished from 22.5% in the first two robotic groups to 6.7% in the latter three groups. The rate of pathologic nodal upstaging was statistically equivalent to the open thoracotomy group.

CONCLUSIONS

Adoption of a robotic platform for lobectomy for early-stage non-small cell lung cancer by an experienced open thoracic surgeon is safe and feasible, with fewer complications, less blood loss, and equivalent nodal sampling rate even during the learning curve. The conversion to open rate significantly dropped after the first 40 robotic lobectomies, and operative time for robotic lobectomy approached open thoracotomy after 60 cases, after a bimodal curve.

Learning curve of uniportal video-assisted lobectomy: analysis of 15-month experience in a single center

Background

Uniportal video-assisted thoracoscopic (U-VATS) lobectomy has been becoming the technique of choice in an increasing number of centers. The aim of our study was to review our experience, evaluating the learning curve of U-VATS for lung lobectomy and outcomes.

Methods

The prospectively collected clinical data of 43 consecutive patients, undergone U-VATS lobectomy from June 2016 to September 2017, were reviewed. The cumulative sum analysis was applied for defining the completion of learning curve (CLC), evaluating the relationship between operative time and the consecutive number of operations.

Results

The mean operative time of Uniportal VATS lobectomy was 179.93±43.41 min. According to the cumulative sum analysis, the CLC was reached after 25 patients. Using the cut-off of 25 patients, the whole populations was divided in group A (first 25 patients of the experience) and group B (the last 18 patients). The mean operative time in group B was significantly shorter than in group A (164.00±24.46 vs. 191.40±50.45 min, respectively, P=0.04). There were no differences in demographic characteristics, number of removed lymph nodes, chest tube duration, and hospital stay among the two groups. The number of conversions was higher in group A (4 vs. 0; P=0.07), as the number of major complications, like reoperations for bleeding (2 vs. 0; P=0.22). There was no postoperative 30-day-related death.

Conclusions

U-VATS lobectomy seems to be a quite safe and feasible procedure, with a steep learning curve and low complication rate, if performed by experienced surgeons after proper training.

Defining the learning curve in robot-assisted thoracoscopic lobectomy

BACKGROUND

Robot-assisted thoracoscopic lobectomy has been shown to be a safe approach to pulmonary lobectomy. This study sought to define, mathematically, the learning curve for RATS lobectomy.

METHODS

Patients undergoing robot-assisted thoracoscopic lobectomy at a single institution from 2010 through 2016 were considered. Covariates included patient demographics, comorbidities, operating time, length of stay, estimated blood loss, and postoperative complications. A cumulative sum analysis of operating time was performed to define the learning curve.

RESULTS

A total of 101 patients were included. Three distinct phases of the learning curve were identified: cases 1-22, cases 23-63, and cases 64-101. There was a statistically significant difference in operating time and estimated blood loss between phases 1 and 2 (P < .05, P = .016, respectively) and between phases 1 and 3 (P < .05, P = .006, respectively). There was no statistically significant difference in comorbidities, chest tube duration, length of stay, postoperative complications, or conversion rate across the learning curve.

CONCLUSION

Based on operating time, the learning curve for robot-assisted thoracoscopic lobectomy is 22 cases, with mastery achieved after 63 cases. No differences in length of stay, chest tube duration, conversion rate, or complication rate were observed in the learning curve. Other factors not measured in this study may play a role in the learning process and warrant further study.

How to get the best from robotic thoracic surgery

The application of Robotic technology in thoracic surgery has become widespread in the last decades. Thanks to its advanced features, the robotic system allows to perform a broad range of complex operations safely and in a comfortable way, with valuable advantages related to low invasiveness. Regarding lung tumours, several studies have shown the benefits of robotic surgery including lower blood loss and improved lymph node removal when compared with other minimally invasive techniques. Moreover, the robotic instruments allow to reach deep and narrow spaces permitting safe and precise removal of tumours located in remote areas, such as retrosternal and posterior mediastinal spaces with outstanding postoperative and oncological results. One controversial finding about the application of robotic system is its high capital and running costs. For this reason, a limited number of centres worldwide are able to employ this groundbreaking technology and there are limited possibilities for the trainees to acquire the necessary skills in robotic surgery. Therefore, a training programme based on three steps of learning, associated with a solid surgical background and a consistent operating activity, are required to obtain effective results. Putting this highest technological innovation in the hand of expert surgeons we can assure safe and effective procedures getting the best from robotic thoracic surgery.

Treatment of pulmonary nodule: from VATS to RATS

Background

The incidental detection of solitary pulmonary nodule (SPN) is currently increasing due to the widespread use of computed tomography (CT) during the follow up in oncological patients or in screening trials. A quick and definitive histological diagnosis of these nodes is mandatory as, in case of primitive lung cancer, an early detection could improve both surgical results and prognosis. The minimally invasive pulmonary resection (MIPR) is the gold standard procedure for diagnosis and treatment of small lung nodules, but it can be difficult to localize deep nonpalpable nodes that lie in the lung parenchyma. Hence, throughout the years several techniques have been developed to better localize deep or sub solid nodes. We describe our experience with radio-guided technique.

Methods

Patients with SPN smaller than 10 mm and/or with a distance from the visceral pleura equal or larger than 10 mm underwent MIPR after CT injection of a solution containing 0.2 mL ⁹⁹Tc-labelled human serum albumin microspheres and 0.1 mL of non-ionic contrast. During surgical procedures, a collimated probe, connected to a gamma-ray detector, was used to scan the lung and detect the target area. The area of major radioactivity was then resected.

Results

Between 2010 and 2015, 175 patients (M/F: 97/78) underwent minimally invasive resection (thoracoscopic or robotic) with radio-guided technique. The mean node diameter was 13 mm (range, 5-20 mm), and the mean distance from the visceral pleura was 15 mm (range, 6-39 mm). No significant CT-guided-injection-related complications occurred, except for 13 patients (7.4%) who developed a pneumothorax (PNX) not requiring chest tube insertion. This technique guaranteed a successfully intra-operative node localization in 100% of cases. The mean duration of the surgical procedure was 44 min (range, 25-130 min). The mean length of pleural drainage and mean hospital stay was 2.6 days (range, 1-5 days) and 3.9 days (range, 1-7 days) respectively. No mortality or perioperative complications occurred. Pathology reports showed 105 metastases, 55 primitive lung cancers and 15 benign lesions. In case of suspicion of primitive lung tumour an intraoperative frozen exam was conducted, and all patients underwent lobectomy or segmentectomy with lymphadenectomy [41 patients with thoracotomy, 11 with robotic surgery and 3 with video-assisted thoracoscopic surgery (VATS)].

Conclusions

Our experience confirms that radio-guided thoracoscopic surgery (RGTS) is a feasible and safe procedure, thanks to its high success rate the radio-guided technique is helpful to overcome the lack of tactile feedback during MIPR [VATS and robotic-assisted thoracoscopic surgery (RATS)] and to limit conversion to open surgery.

Training in robotic thoracic surgery

The best way to teach robotic thoracic surgery is still being decided. New trainees, experienced video-assisted thoracoscopic surgery (VATS) surgeons, and predominantly open surgeons each have different needs when it comes to learning robotic surgery. The data shows that the learning curve and ability to learn robotics initially appears to be shorter and easier than surgeons learning VATS. Though the absolute best method for teaching is still under investigation, multiple centers have started to create systematic methods of teaching robotic surgery that increases resident autonomy while still protecting the patient.

Three-dimensional video-assisted thoracic surgery for pulmonary resections: an update

Video-assisted thoracic surgery (VATS) allows to treat pulmonary and mediastinal diseases although two-dimensional (2D) imaging can make difficult to estimate the morphological and topographical characteristics of a lesion. Some technical aspects have certainly been corrected with the introduction of robot-assisted thoracic surgery (RATS), although not widespread in less economically developed countries. As an emerging imaging system and technique, 3D VATS is an interesting resource for thoracic surgeons and it may be a proper and valid aid in minimally-invasive surgery, but not an alternative or a compromise to the most expensive robotic technology. The purpose of the study was to carefully analyze the different experiences reported in literature in order to evaluate the state of art of 3D VATS method in lung excision.

Robotic lobectomies: when and why?

During the last decade, an abundance of papers has supported minimally invasive pulmonary resections (MIPR) vs. traditional open approach. Both video assisted thoracic surgery (VATS) and robotic thoracic surgery have shown better perioperative outcomes and equivalent oncologic results compared with thoracotomy, confirming the effectiveness of the MIPR. Despite the profound changes and improvements that have taken place throughout the years and the increasing use of robotic system worldwide, the controversy about the application of robotic surgery for lung resections is still open. Some authors wonder about the advantages of using a more expensive and more complex platform for thoracic surgery instead of the more established VATS technique. Robotic thoracic surgery represents, although the cumulative experience worldwide is still limited and evolving, a significant evolution over VATS, nonetheless several authors criticize the longer operative time and the high costs of robotic procedures. The aim of this paper is to answer two relevant questions: why and when the application of robotic technology in thoracic surgery is appropriate?

Robotic assisted lobectomy for locally advanced lung cancer

Some series report the use of video-assisted thoracic surgery (VATS) in patients with locally advanced non-small cell lung cancer (NSCLC) but, few studies describe the use of the robotic approach specifically for locally advanced disease. One potential advantage of the robotic approach over traditional VATS is the increased radicality. While the benefit of the robotic approach over open thoracotomy is directly related to reduced surgical trauma and the improved tolerability in fragile patients that have received induction treatment. In case of occult N2 disease, robotic assisted surgery can translate into a quicker recovery with improved compliance with adjuvant treatments following surgery. Technical details are reported and described. The robotic instrument technology allows sharp and controlled dissection compared to the typical blunt sweeping methods used in most VATS lobectomy techniques. The authors believe that robotic technology favors a more radical resection in the case of complex locally advanced tumors. Robotic technology has some limitations that have affected adoption such as significant capital and maintenance costs, reduced operating room efficiencies, and a steep learning curve.

Robotic lung resections: video-assisted thoracic surgery based approach

Advances in technology cause major developments in minimally invasive thoracic surgery practice. The expected benefits of minimally invasive pulmonary surgery are clear and mostly as follows; shorter hospital stay, fast recovery, less pain, and decreased morbidity and mortality. Robotic surgery with improved visualization and instrumental technical capabilities has become an attractive tool for surgeons who are performing lung resections. However, robotic surgery still seems far away from standardization even in the basic fundamental which is "the best approach for docking". In this article, we would like to share our experience in robotic surgery with video-assisted thoracic surgery (VATS) based or in other terms "robotic-assisted" approach, and discuss its advantages and disadvantages. We speculate that, especially at early experience, VATS based approach or "robotic-assisted approach" may provide a smooth start up with the support of the experienced table surgeon.

Nationwide Assessment of Robotic Lobectomy for Non-Small Cell Lung Cancer

BACKGROUND

Robotic lobectomy has been described for non-small cell lung cancer (NSCLC). Our objectives were to (1) evaluate the use of robotic lobectomy over time, (2) identify factors associated with its use, and (3) assess outcomes after robotic lobectomy compared with other surgical approaches.

METHODS

Stage I to IIIA NSCLC patients were identified from the National Cancer Data Base (2010 to 2012). Trends in robotic lobectomy were assessed over time, and multivariable logistic regression models were developed to identify factors associated with its use. Propensity-matched cohorts were constructed to compare postoperative outcomes after robotic lobectomy with thoracoscopic and open lobectomy.

RESULTS

Lobectomy was performed in 62,206 patients by open (n = 45,527), thoracoscopic (n = 12,990), or robotic (n = 3,689) procedures at 1,215 hospitals. Between 2010 and 2012, robotic lobectomy significantly increased, from 3.0% to 9.1% (p < 0.001). Academic (odds ratio, 1.55; 95% confidence interval, 1.04 to 2.33) and high-volume hospitals (odds ratio, 1.49; 95% confidence interval, 1.04 to 2.14) were associated with increased use of robotic lobectomy. Length of stay was shorter in robotic lobectomy compared with open lobectomy (6.1 vs 6.9 days; p < 0.001). Fewer lymph nodes (9.9 vs 10.9; p < 0.001) and 12 or more nodes were examined less frequently (32.0% vs 35.6%; p = 0.005) in robotic resections than in thoracoscopic resections. There was no difference between robotic and open or robotic and thoracoscopic lobectomy patients in margin positivity, 30-day readmission, and deaths at 30 and 90 days.

CONCLUSIONS

Robotic lobectomies have significantly increased in stage I to IIIA NSCLC patients, with outcomes similar to other approaches. Additional studies are needed to determine if this technology offers potential advantages compared with video-assisted thoracoscopic operations.

Comparison of Video-Assisted Thoracoscopic Surgery and Robotic Approaches for Clinical Stage I and Stage II Non-Small Cell Lung Cancer Using The Society of Thoracic Surgeons Database

BACKGROUND

Data from selected centers show that robotic lobectomy is safe and effective and has 30-day mortality comparable to that of video-assisted thoracoscopic surgery (VATS). However, widespread adoption of robotic lobectomy is controversial. We used The Society of Thoracic Surgeons General Thoracic Surgery (STS-GTS) Database to evaluate quality metrics for these 2 minimally invasive lobectomy techniques.

METHODS

A database query for primary clinical stage I or stage II non-small cell lung cancer (NSCLC) at high-volume centers from 2009 to 2013 identified 1,220 robotic lobectomies and 12,378 VATS procedures. Quality metrics evaluated included operative morbidity, 30-day mortality, and nodal upstaging, defined as cN0 to pN1. Multivariable logistic regression was used to evaluate nodal upstaging.

RESULTS

Patients undergoing robotic lobectomy were older, less active, and less likely to be an ever smoker and had higher body mass index (BMI) (all p < 0.05). They were also more likely to have coronary heart disease or hypertension (all p < 0.001) and to have had preoperative mediastinal staging (p < 0.0001). Robotic lobectomy operative times were longer (median 186 versus 173 minutes; p < 0.001); all other operative measurements were similar. All postoperative outcomes were similar, including complications and 30-day mortality (robotic lobectomy, 0.6% versus VATS, 0.8%; p = 0.4). Median length of stay was 4 days for both, but a higher proportion of patients undergoing robotic lobectomy had hospital stays less than 4 days (48% versus 39%; p < 0.001). Nodal upstaging overall was similar (p = 0.6) but with trends favoring VATS in the cT1b group and robotic lobectomy in the cT2a group.

CONCLUSIONS

Patients undergoing robotic lobectomy had more comorbidities and robotic lobectomy operative times were longer, but quality outcome measures, including complications, hospital stay, 30-day mortality, and nodal upstaging, suggest that robotic lobectomy and VATS are equivalent.

Robotic Surgery for Thoracic Disease

Robotic surgeries have developed in the general thoracic field over the past decade, and publications on robotic surgery outcomes have accumulated. However, controversy remains about the application of robotic surgery, with a lack of well-established evidence. Robotic surgery has several advantages such as natural movement of the surgeon's hands when manipulating the robotic arms and instruments controlled by computer-assisted systems. Most studies have reported the feasibility and safety of robotic surgery based on acceptable morbidity and mortality compared to open or video-assisted thoracic surgery (VATS). Furthermore, there are accumulated data to indicate longer operation times and shorter hospital stay in robotic surgery. However, randomized controlled trials between robotic and open or VATS procedures are needed to clarify the advantage of robotic surgery. In this review, we focused the literature about robotic surgery used to treat lung cancer and mediastinal tumor.

[Implementation of a robotic video-assisted thoracic surgical program]

AIMS

Recent publications from North America have shown the benefits of robot-assisted thoracic surgery. We report here the process of setting up such a program in a French university centre and early results in a unit with an average treatment volume.

METHODS

Retrospective review of a single institution database. The program was launched after a 6-month preparation period.

RESULTS

From January 2012 to January 2013, totally endoscopic, full robot-assisted procedures were performed on 30 patients (17 males). Median age was 54 [Q1-Q3, 48-63] years and ASA score 2 [1,2]. Operative procedures included thymectomy (9 ; 30%), lobectomy with nodes resection (11 ; 38%), segmentectomy (4 ; 14%), lymphadenectomy (3 ; 10%), Bronchogenic cyst (2, 5%) and posterior mediastinal mass resection (1 ; 3%). No conversion was required. Median blood loss was 50mL [10-100]. Median operating time was 135 min (105-165) including 30 min [20-40] for docking, 90min for robot-assisted operating [70-120] and 15 min [10-15] for lesion extraction. CO2 insufflation was used in 28 cases (93%). Hospital stay was 4 days [4-6] with 6 minor complications (20%) (Grade 1 according to the Clavien-Dindo classification). After a median 4 months follow-up [2-7], all patients were alive and demonstrated a good quality of life.

CONCLUSION

This series suggests that full robotic thoracic procedures are safe and effective treatment for various pathologies, with low morbidity and without a significant learning curve, even in a lower volume centre. This technology should accompany the development of minimally invasive thoracic surgery. The importance of robotic training should be emphasized to optimize procedures and costs.

Robotic video-assisted thoracoscopic lung resection for lung tumors: a community tertiary care center experience over four years

INTRODUCTION/BACKGROUND

After its initial description in 1990, video-assisted thoracoscopic surgery (VATS) has emerged as the minimally invasive approach for lung resection in early lung cancer.

METHODS

A retrospective review of prospectively collected data on patients who underwent robotic pulmonary resection for cancer by a single surgeon, between years 2009 and 2013, was performed. Age, gender, type and duration of surgery, length of stay, estimated blood loss, early and late complications, follow-up time, and local recurrence were reviewed and analyzed descriptively.

RESULTS

Three hundred and thirty-one patients underwent the procedure for pulmonary neoplasm. Two hundred and fifty-nine (79%) patients underwent anatomic lobectomies, 56 (17%) patients had wedge resection, while five (1.5%) patients underwent pneumonectomy. In 11 patients, no pulmonary resection was performed for different reasons. Most common neoplasm was adenocarcinoma (185, 56%). All procedures involved a systematic mediastinal and hilar lymph node exploration and removal of suspicious nodes. Twenty-six (6.9%) procedures were converted to open thoracotomy. Mean duration of surgery was 185.63 min. Mean length of hospital stay was 5.52 days. Mean estimated blood loss (EBL) was 47.85 ml. Mean follow-up was 249.41 days (20-1550 days), and five (1.5%) patients developed local recurrence. Early complications were seen in 29 patients (8.8%), most commonly cardiac arrhythmias (20, 6%).

CONCLUSION

Robotic video-assisted thoracoscopic surgery is feasible in lung lesions, with all the advantages of VATS in terms of decreased length of stay and decreased blood loss with local recurrence rate and complication rate comparable to open procedures. There is a clear need for more studies comparing the apparent advantages of robotic-assisted surgery with increased cost of technology.

Comparing robotic lung resection with thoracotomy and video-assisted thoracoscopic surgery cases entered into the Society of Thoracic Surgeons database

OBJECTIVE

The use of robotic lung surgery has increased dramatically despite being a new, costly technology with undefined benefits over standard of care. There is a paucity of published comparative articles justifying its use or cost. Furthermore, outcomes regarding robotic lung resection are either from single institutions with in-house historical comparisons or based on limited numbers. We compared consecutive robotic anatomic lung resections performed at two institutions with matched data from The Society of Thoracic Surgeons (STS) National Database for all open and video-assisted thoracoscopic surgery (VATS) resections. We sought to define any benefits to a robotic approach versus national outcomes after thoracotomy and VATS.

METHODS

Data from all consecutive robotic anatomic lung resections were collected from two institutions (n = 181) from January 2010 until January 2012 and matched against the same variables for anatomic resections via thoracotomy (n = 5913) and VATS (n = 4612) from the STS National Database. Patients with clinical N2, N3, and M1 disease were excluded.

RESULTS

There was a significant decrease in 30-day mortality and postoperative blood transfusion after robotic lung resection relative to VATS and thoracotomy. The patients stayed in the hospital 2 days less after robotic surgery than VATS and 4 days less than after thoracotomy. Robotic surgery led to fewer air leaks, intraoperative blood transfusions, need for perioperative bronchoscopy or reintubation, pneumonias, and atrial arrhythmias compared with thoracotomy.

CONCLUSIONS

This is the first comparative analysis using national STS data. It suggests potential benefits of robotic surgery relative to VATS and thoracotomy, particularly in reducing length of stay, 30-day mortality, and postoperative blood transfusion.

Total port approach for robotic lobectomy

Robotic surgery is safe and efficient, with similar survival rates to the open and video-assisted thoracoscopic surgery (VATS) approaches. The surgeon can provide an R0 resection in patients with cancer. Technical modifications lead to decreased operative times and may improve the ability to teach. The capital cost, service contract costs, and equipment costs have to be carefully considered and studied, and patient selection is critical. There are few achievable benefits of using a robotic system compared with VATS when performing a sympathotomy for patients with hyperhidrosis or a pulmonary wedge resection for tissue diagnosis for patients with interstitial lung disease.

Robotic thoracic surgery: technical considerations and learning curve for pulmonary resection

Retrospective series indicate that robot-assisted approaches to lung cancer resection offer comparable radicality and safety to video-assisted thoracic surgery or open surgery. More intuitive movements, greater flexibility, and high-definition three-dimensional vision overcome limitations of video-assisted thoracic surgery and may encourage wider adoption of robotic surgery for lung cancer, particularly as more early stage cases are diagnosed by screening. High capital and running costs, limited instrument availability, and long operating times are important disadvantages. Entry of competitor companies should drive down costs. Studies are required to assess quality of life, morbidity, oncologic radicality, and cost effectiveness.

Robotic surgery for lung cancer

During the last decade the role of minimally invasive surgery has been increased, especially with the introduction of the robotic system in the surgical field. The most important advantages of robotic system are represented by the wristed instrumentation and the depth perception, which can overcome the limitation of traditional thoracoscopy. However, some data still exist in literature with regard to robotic lobectomy. The majority of papers are focused on its safety and feasibility, but further studies with long follow-ups are necessary in order to assess the oncologic outcomes. We reviewed the literature on robotic lobectomy, with the main aim to better define the role of robotic system in the clinical practice.

The prevalence of nodal upstaging during robotic lung resection in early stage non-small cell lung cancer

BACKGROUND

Pathologic nodal upstaging can be considered a surrogate for completeness of nodal evaluation and quality of surgery. We sought to determine the rate of nodal upstaging and disease-free and overall survival with a robotic approach in clinical stage I NSCLC.

METHODS

We retrospectively reviewed patients with clinical stage I NSCLC after robotic lobectomy or segmentectomy at three centers from 2009 to 2012. Data were collected primarily based on Society of Thoracic Surgeons database elements.

RESULTS

Robotic anatomic lung resection was performed in 302 patients. The majority were right sided (192; 63.6%) and of the upper lobe (192; 63.6%). Most were clinical stage IA (237; 78.5%). Pathologic nodal upstaging occurred in 33 patients (10.9% [pN1 20, 6.6%; pN2 13, 4.3%]). Hilar (pN1) upstaging occurred in 3.5%, 8.6%, and 10.8%, respectively, for cT1a, cT1b, and cT2a tumors. Comparatively, historic hilar upstage rates of video-assisted thoracoscopic surgery (VATS) versus thoracotomy for cT1a, cT1b, and cT2a were 5.2%, 7.1%, and 5.7%, versus 7.4%, 8.8%, and 11.5%, respectively. Median follow-up was 12.3 months (range, 0 to 49). Forty patients (13.2%) had disease recurrence (local 11, 3.6%; regional 7, 2.3%; distant 22, 7.3%). The 2-year overall survival was 87.6%, and the disease-free survival was 70.2%.

CONCLUSIONS

The rate of nodal upstaging for robotic resection appears to be superior to VATS and similar to thoracotomy data when analyzed by clinical T stage. Both disease-free and overall survival were comparable to recent VATS and thoracotomy data. A larger series of matched open, VATS and robotic approaches is necessary.

2nd ESMO Consensus Conference on Lung Cancer: early-stage non-small-cell lung cancer consensus on diagnosis, treatment and follow-up

To complement the existing treatment guidelines for all tumour types, ESMO organises consensus conferences to focus on specific issues in each type of tumour. The 2nd ESMO Consensus Conference on Lung Cancer was held on 11-12 May 2013 in Lugano. A total of 35 experts met to address several questions on non-small-cell lung cancer (NSCLC) in each of four areas: pathology and molecular biomarkers, first-line/second and further lines in advanced disease, early-stage disease and locally advanced disease. For each question, recommendations were made including reference to the grade of recommendation and level of evidence. This consensus paper focuses on early-stage disease.

A systematic review and meta-analysis on pulmonary resections by robotic video-assisted thoracic surgery

BACKGROUND

Pulmonary resection by robotic video-assisted thoracic surgery (RVATS) has been performed for selected patients in specialized centers over the past decade. Despite encouraging results from case-series reports, there remains a lack of robust clinical evidence for this relatively novel surgical technique. The present systematic review aimed to assess the short- and long-term safety and efficacy of RVATS.

METHODS

Nine relevant and updated studies were identified from 12 institutions using five electronic databases. Endpoints included perioperative morbidity and mortality, conversion rate, operative time, length of hospitalization, intraoperative blood loss, duration of chest drainage, recurrence rate and long-term survival. In addition, cost analyses and quality of life assessments were also systematically evaluated. Comparative outcomes were meta-analyzed when data were available.

RESULTS

All institutions used the same master-slave robotic system (da Vinci, Intuitive Surgical, Sunnyvale, California) and most patients underwent lobectomies for early-stage non-small cell lung cancers. Perioperative mortality rates for patients who underwent pulmonary resection by RVATS ranged from 0-3.8%, whilst overall morbidity rates ranged from 10-39%. Two propensity-score analyses compared patients with malignant disease who underwent pulmonary resection by RVATS or thoracotomy, and a meta-analysis was performed to identify a trend towards fewer complications after RVATS. In addition, one cost analysis and one quality of life study reported improved outcomes for RVATS when compared to open thoracotomy.

CONCLUSIONS

Results of the present systematic review suggest that RVATS is feasible and can be performed safely for selected patients in specialized centers. Perioperative outcomes including postoperative complications were similar to historical accounts of conventional VATS. A steep learning curve for RVATS was identified in a number of institutional reports, which was most evident in the first 20 cases. Future studies should aim to present data with longer follow-up, clearly defined surgical outcomes, and through an intention-to-treat analysis.

Robotic lobectomy for non-small cell lung cancer

Over the last 5 years, there has been a tremendous increase in the interest in and use of robotics in thoracic surgery. The focus of this review is on the use of robotics for pulmonary lobectomy, which is being approached with 3 or 4 arm techniques. Early experiences suggest that the learning curve is approximately 20 cases for most surgeons but could be shortened with previous advanced thoracoscopic skills. Robotic lobectomy is feasible and safe in limited reports from experienced centers. Operative and clinical outcomes favor robotic lobectomy over open and appear to be similar to VATS. Limited data on oncologic effectiveness and survival suggest that robotics is similar to VATS. Widespread adoption and integration into practice will require future research efforts to prove oncologic and survival benefits in concert with cost effectiveness evaluation.

Video-assisted thoracoscopic pulmonary resections - The Melbourne experience

BACKGROUND

Despite its privileged economic and educational place in the world, Melbourne was relatively slow to embrace video-assisted thoracic surgery (VATS) for lobectomy. The initial driver of this was Professor C Peter Clarke at the Austin Hospital at the beginning of the new millennium. His legacy was carried on by his apprentice, but at St Vincent's Hospital. After a period of slow development, it became the procedure of choice from 2005, and began to filter sporadically to other hospitals from 2010.

METHODS

This paper details the historical development, techniques and results of 343 VATS pulmonary resections (including lobectomies, sub-lobar anatomical resections, sleeve resections, bi-lobectomies and pneumonectomies).

RESULTS

In-hospital and 30-day mortality was 2.0% and 5-year survival for all stages of NSCLC was 70%. Over 36% of patients were stage II-III using the new 7(th) revision TNM staging system. The conversion to thoracotomy rate was 4.7%. The estimated learning curve for this experience VATS lobectomy appears to be in the range of 15-20 cases. In this series, the same lymph node dissection or sampling was attempted and usually achieved as would have occurred at thoracotomy.

CONCLUSIONS

The results confirm the findings of other large case series that the benefits of a minimally invasive approach are achieved without compromising the long-term survival.